The effect of a contact‐based intervention on attitudes and intended behaviors of nursing students toward people with mental illness: A quasi‐experimental study

Abstract Background and Aim Although nursing students are professionally and ethically trained and educated to respect patients with a variety of medical and mental problems, they continue to exhibit negative attitudes and behaviors toward mental disease and patients with mental illness. The accumulated evidence indicates that contact‐based intervention (CBI) is helpful in enhancing nursing students' attitudes and behaviors toward patients with mental illness. Although evidence found to support the CBI, culture and settings might play a significant role to decide its effectiveness. This would call for testing further the effectiveness of CBI across cultures and healthcare settings. The purpose of this study was to assess the effect of a CBI on the attitudes and intended behaviors of nursing students in Jordan toward people with mental illness. Methods A quasi‐experimental, pre–post, design was used. Data were collected from 81 nursing students from two nursing schools implementing the CBI using self‐reported questionnaires to measure students' attitudes and intended behaviors toward people with mental illness. Data were collected during the first semester of the academic year 2019/2020. The paired‐samples and independent‐samples t tests were used to test the study's hypotheses. Results At baseline, the results indicated that there were no statistically significant differences between the experimental and control groups in terms of their attitudes and intended behaviors toward people with mental illness. At posttest, statistically significant improvements in the attitudes and intended behaviors of nursing students found in the experimental group and between control and experimental groups toward people with mental illness compared with baseline pretest measures (p < 0.001). Conclusion The CBI did improve the attitudes and intended behaviors of Jordanian nursing students toward people with mental illness. Significant implications for nurses were discussed.


| INTRODUCTION
Although nursing students are professionally and ethically trained and educated to respect patients with medical and mental problems, they continue to exhibit negative attitudes and behaviors toward mental illness and patients with mental illness. 1,2 Nursing students have a high level of unfavorable negative attitudes toward patients with mental illness, including an assumption of danger, unpredictability, and a desire for social distance. 3 These attitudes have found to be detrimental to students' performance including the use of nontherapeutic communication, while caring of patients with mental illness. 4 These attitudes might contribute to lower quality of nursing care and adversely affecting patient outcomes. 5,6 This would call for finding out means to combat nursing students' negative attitudes and intended behaviors during their theoretical and clinical training courses.
Three primary strategies for combating negative attitudes and behaviors among students were presented in the literature: protest, education, and contact. 7 Contact, the most promising strategy, relates to interpersonal interactions between members of the general public and individuals with mental illness, 8 but protest and education have significant limitations. 7 Contact-based intervention (CBI) has also been showed to lessen nursing students' fear, perceived danger, avoidance, segregation, and coercive attitudes toward people with mental illness. 9 Additional research revealed that CBI resulted in a positive shift in attitudes, an increase in empathy, and a positive shift in the intentions of nursing students to seek a profession in mental health nursing in the future. [10][11][12][13] The accumulated evidence indicate that CBIs are helpful in enhancing nursing students' attitudes and intended behaviors toward patients with mental illness. 14 Although evidence found to support the CBI, previous studies are inconsistent and have methodological limitations, as well as lack long-term followup data on the sustainability of CBI effect. 7 Furthermore, culture and settings might play a significant role to decide its effectiveness. For example, in Jordan, the healthcare systems, treatment protocols, available facilities for mental health care, and shortage of workforce might influence the recovery process of patients with mental illness, and consequently, nurses and nursing students' perception. This would call for testing further the effectiveness of CBI across cultures and healthcare settings. Furthermore, nursing students found to suffer higher levels of academic anxiety and depressive symptoms due to mandate academic assignments and training needs. 15,16 Further, studies have also reported that university students, in general, are suffering various forms of psychological disturbances such substance use, deliberate self-harm, and premenstrual dysphoric disorder 17,18 that might influence their behaviors and attitudes.
In Jordan, similar to international reports, stigma is observed against mental illness and patients with mental illness and their families. 19,20 Negative attitudes were also reported among nurses toward patients with mental illness and mental illness, 5 and among nursing students toward patients with mental illness, 1 which may indicate the need for intervention to combat negative attitudes and behaviors of nursing students. The challenges that are facing nursing education, nowadays, are also signifying the importance of the study. 21 Therefore, there is a need to experiment the proposed CBI approach to correct attitudes and intended behaviors among nursing students and nurses. Focusing on nursing students would give an indication for nurse educators and clinicians about the real needs and areas of defects in nursing education and training that need to be corrected. Therefore, this study aims to assess the effect of a CBI on the attitudes and intended behaviors of nursing students in Jordan toward patients with mental illness. The study hypotheses were as follows: (1) In the experimental group, nursing students will report more positive attitudes and intended behaviors toward people with mental illness postintervention compared with the baseline and (2) at the posttest, Jordanian nursing students in the experimental group will report more positive attitudes and intended behaviors toward people with mental illness than control group.

| Design
This study utilized a quasi-experimental nonequivalent control group pretest-posttest design to examine the impact of a CBI on attitudes and intended behaviors of nursing students toward people with mental illness. Data were collected in relation to attitudes and intended behaviors toward people with mental illness using selfadministered questionnaires at two points of time (before and after the CBI).

| Sample and settings
Nursing students were recruited from two nursing schools (one public and one private) in Jordan. The two schools selected randomly per cluster (private vs. public). Nursing students recruited conveniently from the two selected schools. Inclusion criteria included: (1) nursing students enrolled regularly, (2)

| The sample power
A power analysis was conducted to determine the appropriate sample size using the G*Power computer software program version 3.0.10. 23 In the current study, a paired-samples t test test was used; a small effect size of 0.25 was determined, a significance level of α = 0.05 was set, and at a power of 0.90. The yielded sample was 34 participants, at least, for each group. Subsequently, the overall sample size was 68, at least, for the 2 groups. However, 10% (~7 subjects) of the total sample size were added to account for any refusal and dropout. Accordingly, 81 subjects were recruited (41 in the intervention group and 40 in the control group).

| The intervention
In the current study, the implemented CBI included a presentation done by two volunteered persons with mental illness who disclosed mental health challenges, treatment, and recovery to the participated nursing students in the classrooms at the selected nursing schools. The two persons with mental illness, who are mentally stable and hold down jobs, were recruited from a national nonprofit association, which is led by persons with mental illness and is dedicated to support and defend the rights of people with mental illness. Both persons were not socially nor occupationally impaired, their cognitive ability was intact, and their psychological symptoms were remitted. Those people have been invited to meet with nursing students. The persons with mental illness were diverse in term of sex (male and female) and were trained before going to each nursing school where they interacted with the participated nursing students. The implemented CBI included written material in the form of a brochure to disseminate more information in the meeting. In each nursing school, the CBI involves 30 min live interaction session between the two persons with mental illness and nursing students in the classrooms of the nursing schools. In this session, the persons with mental illness provided personal testimonies describing personal perspectives and experiences of having a mental illness. The implemented CBI discussed "on the way down" and "on the way up" stories of the persons with mental illness. "On the way down" stories discussed suffering, illness, and disabilities, whereas "on the way up" stories discussed the way to recovery and success. In addition to the participated nursing students and the persons with mental illness, the implemented CBI involved a psychiatric nurse. The role of the psychiatric nurse was to supervise the implemented CBI by facilitating the interaction between the participated nursing students and the persons with mental illness. In addition, the psychiatric nurse was responsible for conducting the questions-answers session. The psychiatric nurse was recruited to intervene appropriately in the cases of expected emotional distress that might be experienced by the participated nursing students or the persons with mental illness. After that, 15 min for facilitated audience discussion in the form of questions and answers was conducted. Upon completion of the session, the researcher distributed the self-reported questionnaire to the participating nursing students and answer any related inquiries.
Intervention fidelity is the adherence of an intervention to the protocol. A checklist was used to document the fidelity of the implemented CBI on the members of the intervention group. It measured the pace and timing of the CBI, the engagement of the participated nursing students, and the role of the psychiatric nurse and the persons with mental illness.

| Data collection procedure
After obtaining ethical approval from targeted universities and approval from the volunteered charitable institution, data collection started during the first semester of the academic year 2019/2020.
The persons with mental illness were recruited from the interested and willing members in the institution. They were informed about the study in details. Consequently, they provided consent to indicate their agreement to take part in this study. Then, they were informed by phone the time and location for each session. The nursing students were recruited through school administrator who volunteer to invite students through contact-based information system per school. The invitation included contact information of the research team. Interested students were informed about the study purpose and significance. Then, the interested ones directed to meet with the research team to sign the consent form.
In the first week and at each nursing school alone, students were asked to leave the class quietly if they had any mental illness or a history of mental illness. Students who were willing to meet people with mental illness were recruited in the intervention group, whereas students who preferred to receive no intervention but want to take part in the study were directed to the control group.
Assigning students to intervention and control group was based on their preference, as some students were willing to interact with the persons with mental illness, while others were not willing. Subsequently, the data were collected by the researcher using the self- In the second week and at each nursing school alone, the control group was asked to complete the same self-reported questionnaire filled in the first week. Then, the members of the control group were asked to kindly leave the classrooms before the CBI begins; as a result, only the members of the intervention group stayed in the classrooms. Subsequently, the CBI took place among the members of the intervention group only, under the supervision of the researcher, and lasted around 30 min. After the CBI finished, a 15 min session for questions and answers between the participated nursing students at the intervention group and the persons with mental illness took place, and was facilitated by the researcher. Subsequently, the data were collected by the researcher from the members of the intervention group using the same self-reported questionnaire that was administered in the first week. The collected data from both groups at 2 weeks were kept in a password-secured computer. mental illness were informed about the study, the potential benefits and risks, and their rights. Those who agreed to take part in this study provided informed consent.

| Instrumentation
Data has been collected using the Arabic version of the tools. Two scales were used in this study, in addition to a researcher-developed questionnaire to collect the demographic data including age, gender, family month income, university, and previous contact with people with mental illness. The two scales were as follows: 1. The MICA v4 scale 24  In the experimental group, 29 students (70.7%) were females.
The mean age was 19.15 years (SD = 0.76), ranging from 18 to 22 years. All the students were sophomores. In the control group, 23 students (57.5%) were females. The mean age was 19.90 years (SD = 0.84), ranging from 18 to 22 years. Twenty-eight students (70%) were sophomores.   Table 3

| Testing differences between experimental and control group
To test Hypothesis 2, an independent-samples t test was performed to find out if nursing students in experimental and control group are different at the posttest in their attitudes and intended behaviors toward people with mental illness. All the assumptions of the pairedsamples t test were checked and met before conducting the analysis.
The results (see Table 4) revealed that there were statistically

| DISCUSSION
Negative attitudes of nursing students toward patient with mental illness and mental illness, in general, has negative impact on quality of care provided and do negatively influence nursing students' preference to specialize in psychiatric care. This study proposed an intervention that combat nursing students' negative attitudes and intended behaviors. We found that using CBI has improved (minimized) nursing students' negative attitudes and intended behaviors toward patient with mental illness and mental illness. The improvement (being less negative) in attitudes and intended behaviors have been observed among students in experimental groups at pre-and postintervention and between control and experimental T A B L E 2 The differences between the experimental and control groups regarding the attitudes and intended behaviors toward people with mental illness, at the baseline measure (pretest) groups at both times (pre and post). This indicates that CBI is promising approach that can be applied at nursing schools as one preparatory stage for students before sending them to psychiatric care settings. The results support previous reports that CBI had positive influence on nursing students' attitudes and behaviors. 9,12 The study emphasized the importance of introducing such an experience for nursing students for number of benefits including students' preference to intention to pursue a career in mental health nursing in the future that has been also reported by Happell et al. 10 Also, fear and stereotypical and negative assumptions toward patients with mental illness and mental illness have been counteracted. 9 Although some researchers reported that nursing students' courses and students have the right to receive appropriate preparation before being sent to training area. This is why high-fidelity simulation has been proposed in nursing education and found to be successful and did enhance patients' safety and quality of nursing education and training. 27 The option whether to use simulation lab or using the CBI as approaches is of equivalent benefits to students and patients. This is also similar to what has been reported by researcher who have used both types of social contact (Live and video-based) between nursing students and people with mental illness and had positive outcomes. 28 Itzhaki et al. 11 have also found that a mental health nursing course that involved face-to-face meetings with three individuals with mental illness and a film on a doctoral degree holder who talked about living with mental illness, resulted in improvement of the attitudes of nursing students toward patients with mental illness.
Other researcher 29 found that nursing students who attended either live or DVD-based contact reported more positive attitudes and behaviors toward people with mental illness than nursing students who attended a lecture about stigma of mental illness. No significant differences were found between the live and DVD's groups. The inconsistent findings of these studies might be attributed to the fact that these studies have used different measures to assess the attitudes and behaviors of nursing students toward people with mental illness. These studies also have not used identical components of the live and video-based social contact interventions; some variations have existed. Therefore, it seems that it is not possible to determine which type of social contact is more effective in improving the attitudes and behaviors of nursing students toward people with mental illness.
One limitation of this study is related to using pre-post only. A long-term follow-up assessment would be more informative. Previous research reported dearth of long-term follow-up data and insights on how to sustain positive changes for longer period of time. 7 One another limitation is the unavailability of a measure for actual behaviors toward people with mental illness. Also, recruiting the persons with mental illness was challenging. Excluding the students who has/had mental illness would also limit the generalizability of the study findings to this category.

| Implications for nursing practice
The current results have significant practice implications for nursing.
One of the potential practical implications is that students will provide compassionate mental health care during their practicum and later as independent nurses. 30  Finally, no additional practice suggestions can be provided until more rigorous data becomes available. 32 However, continued attempts of nurses to address the negative stigmatizing attitudes and behaviors toward people with mental illness, through CBIs and other antistigma approaches, would eventually lead to correcting these negative attitudes and behaviors.

| CONCLUSION
The study found that CBI is a promising approach that can be

ACKNOWLEDGMENT
This study has been conducted as part of requirements for PhD in nursing at The University of Jordan. This research did not receive any specific grant from funding agencies in the public, commercial, or notfor-profit sectors.